Let's Form a Circle

Excerpts from a conversation with former Surgeon General

C. Everett Koop

by Joe Flower


This article originally appeared in The Healthcare Forum Journal, November-December 1992, Vol. 35, #6.

International Copyright 1992 Joe Flower All Rights Reserved
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You remember C. Everett Koop. The man looked great in the uniform of the Surgeon General of the United States - like an admiral of some tall-ship Navy. Then there was that beard, the booming voice, the precise sentences, the old-fashioned authority, and the passion - the passion for the health of Americans, and for the simple public health and educational measures that could and should be taken to improve it. It was one of the charms of the Reagan administration to watch this conservative, old-school pediatrician take on the political handlers in the White House over the question of AIDS, a major public health menace which the president's men seemed to want to ignore.

An MD and a Doctor of Science, Koop has published over 200 articles and books. He served for decades as Professor of Pediatrics at the University of Pennsylvania, and Surgeon-In-Chief of Children's Hospital in Philadelphia, before his appointment as Surgeon General in 1981.

Since he resigned that post in 1989, he has devoted his time to his own foundation, and to the National Safe Kids Campaign (which he chairs). Now, at 76, he has a new vehicle for his lifelong passion, the marriage of health and education. He is working with the Carnegie Foundation for the Advancement of Teaching in an attempt to see that all of America's kids come to school physically and mentally ready to learn. He brings to the task that resounding passion and clarity, and a strong call for America's health care industry to get involved.




Thirty percent of kids who go to kindergarten these days do not know what the teacher means when she says, "let's form a circle." Those kids don't know red from green. They don't know left from right. They have not been mentally stimulated.

That's just half the problem: Polls that have been taken by kindergarten, first- and second-grade teachers indicate that 30 percent of the kids have been deprived in some way so that they are physically unable to keep up with the class. They have been deprived nutritionally, or some illness has not been picked up, or they have not been screened for vision or hearing defects, or they have not had some kind of a chronic illness or error of metabolism picked up. The terrible thing is that the kid's own self-esteem is so damaged. If he can't see or can't hear, it is assumed that he is dumb, stupid, inattentive or doesn't care. He is always the butt of somebody's disapprobation, and in the process he thinks, "I'm no good." And he thinks that there is nothing he can do to correct that.

When a child shows up for school, and is not physically and mentally ready to learn, he or she never catches up. If you have a kid who goes to kindergarten and doesn't know what a circle is, doesn't know what red and green are, and doesn't know what right and left are, by the time he learns those things, the rest of the class is far ahead of him.

That doesn't mean that an exceptionally bright child with good native intelligence, given the stimulation that he needs and the opportunity to learn, won't catch up. But, in general, these kids do not catch up and they are always considered to be slow, or retarded.

The Carnegie Foundation for the Advancement of Teaching has been in existence for most of this century. The foundation was started by Andrew Carnegie, and it is in the business of examining situations in education in the United States and writing reports about them. They have done some very outstanding ones, for example, the Flexnor report was written in 1910 and is still the report on which medical schools are modeled in this country. Johns Hopkins picked up the model in 1912 and said, "We will be the model that others can follow."

So the Carnegie Foundation does have an impact on education in this country. They consider that one of the most important reports they ever made was the one they released on the 10th of last December, called "Ready To Learn." That, incidentally, got its title from the speech President Bush made to the governor's association when he said he wanted to be "the education president." One of the principles in his speech was that he wanted every child entering school, whether that was kindergarten or first grade, to be ready to learn.

The Carnegie Foundation is well aware of the fact that their reports frequently find their way to dusty archives in academic institutions, but occasionally people pick up a segment of a report and act upon it. And they are content with the way that works, usually.

This time, however, they said, "Since we think this is one of the most important reports for the people of this country that we have ever turned out, we would like to devote the next three to five years to implementing that report." This is a unique response of the Carnegie Foundation to one of its own reports. The president of the Carnegie Foundation for the Advancement of Teaching, Ernest Boyer, called me and asked me if I would be willing to be the implementor, with never anything specific said about what that meant. After two or three conversations, I decided that I would do what I could for the following reasons: One, I agree that it is a very important report. Two, it has as its major theme the marriage of health and education. That is something I tried to do during my tenure as surgeon general.

Here is an opportunity to do something I have wanted to do for a long time. In looking over specific recommendations on how things can be done, I was impressed with the fact that I could say that I have had some experience in some of these things, either when I was in pediatrics for all of my life at the Children's Hospital in Philadelphia, or in the kinds of initiatives that I was involved with when I was surgeon general. It seemed like kind of a natural marriage in as much as I was able to seek someone to help me in this endeavor. I felt extraordinarily fortunate to be able to get Dr. Vince Hutchins, who for many years headed the Bureau of Maternal and Child Health in the Public Health Service, and who I think is one of the most respected people in the country in maternal and child health.

Another aspect of this report that I thought was very important for me to assume this role of implementor is that the target audience is not just children from birth to kindergarten. The target audience goes back to conception. That means pre-natal care, safe delivery, post-natal screening, and the ordinary stuff you do in pediatrics. That's why I came on board and that's why Dr. Hutchins and I are pleased to be working together. We have chosen the Ready To Learn Council as the modus operandi. The council is composed of, at the moment, 27 to 28 child advocacy agents who are in the business of the same concerns that we are.

Some of these are obvious, like the American Academy Of Pediatrics and the Children's Defense Fund. You might expect that the American College of Obstetricians and Gynecologists would be there and they are. But then there are other things that you might not expect, such as the National Library Association, because one of the concerns we have is the poor literacy of children. It all starts off with a very poor vocabulary, so one of our concerns is to get kids to be talked to, read to, and engaged in a kind of dialogue.

We also have the Junior League, for example, and people might be wondering why they are here. The reason is is that they are people who pick up balls and run with them. My experience with the Junior League, when I worked in Philadelphia for four years in reference to children's things, is that whenever they were asked they responded. They always responded with sincerity, and they did a good job.

The great advantage about having this council is that they each have a bunch of volunteers in addition to their staff. They are already in an on-going effort to do something about children, and they have so many hundreds of thousands of foot soldiers out there to get the job done. When you talk to the PTA or the preschool PTA, you are talking about an organization with 66,000 chapters with all kinds of parents and teachers eager to do the right thing for kids. I think that we have an army of a couple of million volunteers already geared to the needs of children, and I think they will be responsive as we begin to develop grass roots programs, learn from one another and get America talking about Ready To Learn.

It takes proper parenting for a child to come to school ready to learn. Usually when you talk about something like this it is almost always associated with poverty, 100 percent. But that is no longer the case. Among kids who are not ready to learn when they go to school you find children of "yuppies" who have ample amount of money but no time that they want to devote to their child. These are kids who are deprived of parental stimulation because the parents are out working harder than they probably have to. Children are put into day care centers that do not stimulate them. The parents come home at night dead tired and they put the kid in the crib, turn on the television, go have a drink, eat dinner and then they are ready for bed.

It's not always the yuppies. There are many stressed single parents who may be working two jobs in order to keep the family together. When they come home they are absolutely exhausted and they don't really see themselves ready to sit down and read nursery rhymes with their children.

One of the things we want to do is find ways, first, to impress these parents how important it is to have children in a situation where they can respond to them and, second, to bring intergenerational relationships into play. For example, we would like to get the kids together with retired folks who would love to have something to do and who love children. Many of them are deprived of access to their own grandchildren because of distances. We would love to get them to act as sort of foster grandparents, to read stories and tell stories to children.

I would like to assign to somebody the following task: one of the things that happens to kids all the time at toddler age is that they get dragged to shopping malls by their parents. They are kind of a nuisance for their parents to drag around, so why not have shopping malls build a little thing in the place where they do business called the "storytellers corner." Children can be left there for an hour or an hour and a half by their parents who are shopping. There could be somebody of an older age, who loves children, who would like to sit there and tell them stories. This is vocabulary building, and you get kids answering back. You begin to engage them in a conversation so that they know what words begin to mean.

That's just on the literacy angle. There are all kinds of things you can do to marry literacy with health. For example, you could suggest to folks from the AARP, who might be recruited by that organization to be storytellers to children in a mall, to "be sure that, sometime in your storytelling, you make it clear how important health and wellness is to a child."

I am convinced that one of the things we've missed in this country is educating preschool children to the fact that they can indeed take charge of their health. Although not a Roman Catholic, I happen to be one of those who believes the Jesuits when they say, "Give me a child until he's five and I have him the rest of his life." I think if you take a toddler who's old enough to brush his teeth and tell him that in addition to doing that he also should be eating a proper diet, he should be doing exercise and he should never take drugs, alcohol, tobacco, and so on, I think that you establish a kind of catechism that he may well forget, but he will remember enough of it to come back to it at a time when he might be in crisis.

The thing that reinforces my belief about that is having worked the last four years with the Safe Kids Campaign on a national basis. I am so amazed at what these little kids do in keeping their parents alerted to what they are there for. Kids get in the car and they say "buckle up", and they are only four. I've heard four-year-old kids ask their parents, "Are the batteries in the smoke alarm working?" They are taught that in nursery school, and they come home and they ask their parents.

Now, I'm not a person who thinks kids shouldn't enjoy junk food. I just think that they should not make it a steady diet. We already have established on the basis of pretty well-controlled experiments that if you have children properly taught about nutrition, which would include the kind of foods you purchase and not making a habit of junk foods, that we could influence the purchasing habits, the cooking habits and the eating habits of families at home. There have been some good studies done in California with Hispanic parents where in the course of a year, they have changed their entire nutritional intake for the better. The kid becomes, in a sense, the bridge between the educational process and the home.

You have probably heard your grandfather talk about a sound mind and a sound body - that is exactly what this is: kids getting to school ready to learn because they are both mentally and physically equipped for it. You are never going to be a ready learner if you are starving. An awful lot of kids who are under the poverty line come to school hungry two or three days a week. A little kid who is hungry is not going to pay much attention to forming circles or squares. A lot of kids are showing up hungry, malnourished, in ill health and unstimulated

So we are focussing on what it would take to ensure that all American children come to school ready to learn. If you had all the money in the world, you could afford to go and sprinkle the money in at the top, hope that the right amount got to the bottom of the pile, and that there would be enough good people who would pick up the ball and run with it and see that the things were done.

We are interested in doing that, but we are interested in grass-roots things as well. For example, right now there is going through Congress a "Ready to Learn" bill, which provides for all sorts of things for youngsters. One is having specified times on public television and public radio with educational programs aimed only at children, at the hours of the day when they are likely to be able to enjoy them. There are provisions for "Ready to Learn" clinics, federal grants to states who will match funds to set up clinics. Preferably these clinics will be associated with the schools. They will be able to check the children for health conditions, and they also will be able to give instruction on how parents can do parenting better, provide reading materials and that sort of stuff.

The states are being encouraged. We will be sending out letters to all of the governors, inviting them to appoint people to work with us to establish state programs. And the programs vary. In some rural parts of the world, where there are great distances between houses, there are no kindergartens because the transportation problems are too difficult. The state of New Hampshire, for example, doesn't have that problem, but it does not mandate kindergarten education, as many states do. States that are in the north don't have the same problems that states in the southwest do. The state government knows better what to do with funds than does the national government.

Grass roots participation

I want to see things that come up from the grass roots. I have learned this from my Safe Kids experience. It is almost impossible for an organization, like Safe Kids, to go into a community and tell the mayor and the city council, for instance, that it is possible to set up a program so that no child will ever be scalded in that city by hot water coming out of a shower or a faucet, and get any action. Nothing ever happens.

However, if you go into that community at the grass roots level and you talk to PTAs, church groups and civic organizations and demonstrate that these little springs you can put in a shower head will shut off the water when it gets over 120 degrees, which is scalding temperature, they get very interested in that. When we take our money and buy specific equipment for families who could not possibly afford them or have the necessary drive to go out and purchase them and install them then the community says, "Hey, we've got to do something about these kids who are getting scalded." Then, they go to the city council and they demand that any new houses built have a building code that includes an anti-scald device. Then people start selling them, they have cake sales and buy them for the poor, and it spreads.

We have done this with smoke alarms, with car restraints for small children, with bicycle helmets, and with anti-scald devices, and it works. This doesn't work the same in all communities, because all communities don't have the same problem. There is no point in having a program in New Mexico for the dangers of drowning by walking on thin ice.

That's the kind of approach we are visualizing for Ready to Learn. That is why we are working with these various groups that have volunteers. We can get a lot of these things done. Nobody has dropped out, and a lot of people would like to join. We now know what each other does. We are discussing what we think each of us can start to do in our community, and then we will act here as a clearing house. We will put out a newsletter. We will be using Parenting magazine as a means of reporting to the public.

What health care can do

The health care industry can play a great role in this by being aware of the fact that these children form perhaps the most neglected group of people in the country, largely because it is hard to find them. Once a kid goes to school, you've got him. But when he's between birth and kindergarten, he may be in a nursery or day care center, he may go to Sunday school, but he may not do any of these things. Probably, if you went to organizations that cater to children, you will probably only pick up 30 to 40 percent of the kids. One of our major difficulties is to find kids and make their parents aware of what the discrepancies are in their rearing and how they might be corrected.

I think the average American is ashamed of the statistics which compare us with other industrialized nations. Our statistics show that we were living in the Third World. In some places, it is worse in America than in the Third World. You see people living in some parts of Appalachia who are not as well off as people living in the Third World. The terrible contrast is that if you go on a high hill and look out at the distance, you can see a metropolis there with medical care that is available to everybody.

The health care industry has to be aware that there is this tremendous number of deprived children who are needy. Second, the Ready To Learn effort is the marriage of health with education. We know that no matter how much you present education material to a child who is physically deprived or who is nutritionally below par, he is not going to get 100 percent effect from that kind of exposure. Third, for those people who are in need, the health care industry can provide special clinics and special attention.

We can also have a special alertness to the fact that preschool kids, many times, have never been screened for their nutritional state, their visual acuity, their ability to hear properly, their neurological fitness, and whether they have learning deficits. Lots of kids get to school without anyone picking up on the fact that they do have a learning impairment and that they will require some kind of special education. They have to be screened by somebody and there is nobody better to screen them for many of these things than a health care worker, whether that is a doctor, a nurse, a nurse practitioner or a physician's assistant.

For very special needs children, I think these probably are some that have gotten the best attention. These are the kids who have a severe illness, like juvenile arthritis, cystic fibrosis, severe asthma and neuromuscular defects. These are special needs children for whom a very special effort has to be made, and their education has to be equivalent to that of the kids in the main stream.


The federal legislation provides some money so that health care instituions can help provide these services. It does this by giving federal grants for Ready to Learn clinics. They already have them in Hawaii - Ready To Learn clinics for toddlers, from birth to entry to school.

There are no federal funds available yet because the bill has not been passed, but with federal funds and matching state funds you will have one source of income. If, through the governors, we can stimulate individual states to take concern in this, then I think we have another source of funds.

One of the real trends that is taking place in America today, and it has to do with health care reform, is that the foundations are all thinking in the same direction. Whether you are talking about Rockefeller or the Pew Memorial Trust or the Robert Wood Johnson Foundation, they are all talking about the marriage of health and education which has been so long neglected. The Pews have gone so far as to have a far reaching plan for which they would like to make three states models for the rest of the country. They are willing to put their donation into those states to build the infrastructure, but not to provide the services. They have chosen 10 states that they are educating to best of their ability about what the problems are and what the opportunities are. They hope that by December of this year three of those states will volunteer to do such an experiment. The hook is this: It would be nice to have the millions of dollars that Pew and the other foundations will pour into the infrastructure. But the state then has to provide the services. It will cost the states money, but they will enjoy the lowest cost per capita, because they will include every kid in the state.

It is, in a way, a daunting task. But I think the country is ready for it. There is a lot that the health care industry can do. The time has come to do something about it.

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